UB-04 Completion Guide

Transcription

1 1 2 3a Provider Name, Address, and Telephone Number Enter the provider s name and mailing address and telephone number. The country code is required if outside United States of America. 2 Pay-to Name, Address, and Secondary ID Fields Enter the Pay-to Name and Address. Required when the address for payment is different than that of the Billing Provider in Form Locator 01. 3a Patient Control Number 4 Type of Bill 5 6 Federal Tax Identification Number Statement Covers Period 8 Patient Name/Identifier Enter your account number for the patient. The patient s account number will be listed as the Own Reference Number on the remittance advice. Indicate the Medicaid bill type using one of the following codes: 0111 Admit Through Discharge Claim 0112 Interim First Claim 0113 Interim Continuing Claim 0114 Interim Last Claim 0117 Replacement Claim Enter the facility s Federal Tax Identification Number. Enter the beginning and end dates covered by this bill. The last date entered is the discharge date for Claim Types 0111 and 0114 only. The date format is MM- DD-YYYY. Enter the patient s last name, first name middle initial. For SC Medicaid, DO NOT include the Patient Identifier. Last Updated 05/24/2008 1

2 A - E Patient Address Enter the patient s mailing address, including street number and name or post office box number or RFD, city name, state name and ZIP code. 10 Patient Birth Date 11 Patient Sex 12 Admission/Start of Care Date 14 Admission Type 15 Source of Referral for Admission or Visit Enter the patient s birth date in MMDDYYYY format. If birth date is unknown, indicate zeros for all eight digits. Enter the sex of the patient: M male F female U unknown Enter the actual admission date of the patient, including interim bills. Required for all inpatient claims. Enter the code indicating the priority of this inpatient admission: 1 - Emergency 2 - Urgent Enter the appropriate code indicating the referral source. The applicable codes are: 1 Physician Referral 2 Clinical Referral 4 Transfer from Hospital 6 Transfer from another Health Care Facility 8 Court/Law Enforcement 9 Information not available Last Updated 05/24/2008 2

3 Patient Discharge Status Enter the patient s status as of the through date of the billing period: 01 - Discharged to home or self-care (routine) 04 - Discharged to an Intermediate Care Facility 05 - Discharged to another type of institution for inpatient care or referred for outpatient services to another institution 07 - Left against medical advice or discontinued care 30 - Still a patient Condition Codes 31 Occurrence Codes and Dates Always enter C5 in field 18 for SC Medicaid. C5 = Post Payment Review Applicable Enter the corresponding code, if applicable to this claim that identifies conditions that apply to this billing period. Codes must have 2 digits and must be entered in alpha-numeric sequence. Dates must be six digits and numeric. One entry without the other will generate an edit code. Applicable codes are: 24 - Date of insurance denial 42 - Date of discharge (bill types 0111 and 0114 only) Last Updated 05/24/2008 3

4 The UB-04 has a total of 22 lines for claim detailed information. 42 Revenue Code 43 Revenue Description Enter the appropriate revenue codes. Accommodation and leaves of absence must be listed by revenue code. Consult your NUBC UB-04 Data Specifications Manual for a complete listing. Revenue codes should be entered in ascending order with the exception of revenue code 0001 (total charges) which must always be the last entry. The most commonly used revenue codes are: 0121 Room and Board, Semi-Private 2 Beds 0131 Room and Board, Semi-Private >2 Beds 0151 Room and Board, Ward 0180 Leave of Absence Days* 0270 Medical Supplies- General 0300 Lab 0001 Total Charge (must be last entry) *Leave of Absence Days are not Medicaid reimbursable, and must be deducted from the total number of days billed. Enter a narrative description of the related revenue categories. Abbreviations may be used. 46 Service Units Enter number of days or units of service when appropriate for a revenue code. Last Updated 05/24/2008 4

5 47 The UB-04 has a total of 22 lines for claim detailed information Total Charges 50 Payer Identification 52 Release of Information Certification Indicator 54 Prior Payments - Payer Sum the total charges, lines Enter total charges on line 23 of final page as revenue code Name of health plan that the provider might expect some payment for the bill. If Medicaid is the only payer, enter Medicaid in Field 50 A. If Medicaid is the secondary or tertiary payer, identify the primary payer on line A and enter Medicaid on line B or C. Code indicates whether the provider has on file a signed statement (from the patient or the patient s legal representative) permitting the provider to release data to another organization I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Enter the amount received from the primary payer on the appropriate line when Medicaid is secondary or tertiary. Report all primary insurance payments. Last Updated 05/24/2008 5

6 The UB-04 has a total of 22 lines for claim detailed information National Provider Identifier Enter the facility s 10-digit NPI. 58 Insured s Name Enter the insured s last and first name A - C Insured s Unique Identification Treatment Authorization Code Document Control Number (DCN) Enter the patient s 10-digit Medicaid number on the same lettered line (A, B, or C) that corresponds to the line on which Medicaid payer information was shown in Fields Enter the assigned authorization number from the Prior Authorization Form (DHHS Form 254). This number should be entered on the same lettered line (A, B, or C) that corresponds to the Medicaid line in Field 50. Enter the claim control number (CCN) of the paid Medicaid claim when submitting a replacement or void claim to Medicaid. Last Updated 05/24/2008 6

7 Enter the ICD Diagnosis Code including the fourth and fifth digits where 67 Principal Diagnosis Code applicable. 76 Attending Provider Name and Identifiers Enter the Attending Physician s National Provider Identifier (NPI). 81 Taxonomy Code Enter Qualifying code B3 for Taxonomy code and enter 10-character Taxonomy code. ex. B3322D00000X (Underlined code is sample taxonomy code) Last Updated 05/24/2008 7